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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603604
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:50:03 PM

Document Has Been Signed on 10/29/2024 03:50 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:A BELOVED HOME OF DIAMOND BARFACILITY NUMBER:
198603604
ADMINISTRATOR/
DIRECTOR:		DUONG, MY MYFACILITY TYPE:
740
ADDRESS:454 S ROCK RIVER RDTELEPHONE:
(626) 899-6999
CITY:DIAMOND BARSTATE: CAZIP CODE:
91765
CAPACITY: 6CENSUS: 5DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:30 AM
MET WITH:Genia Polistico, StaffTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cynthia Chan and Luis DeLeon conducted the unannounced annual inspection on 10/29/24. LPAs met with Staff, Genia Polistico, and explained the purpose of the visit. The assistant administrator, Elizah Arganosa, arrived shortly after to assist with the visit. The facility is licensed to serve 6 non-ambulatory residents, ages 60 and over. One may be bedridden and is approved for bedroom #3. There is a hospice waiver approved for 6.

The facility is a single story home with 5 resident bedrooms, 1 staff room, 2 bathrooms, open living room, dining room, and kitchen, laundry room, and attached garage. Garage has an additional storage room. There is no swimming pool on the premises. The bathrooms have non-skid mats in the shower area and grab bars. Facility has smoke and carbon monoxide combo detectors that are operable and interconnected. Knives, cleaning solutions, and disinfectants are locked, making them inaccessible to residents. The facility has auditory devices on the exit doors. There is a sufficient food supply of 2 day perishable and at least a week of non-perishable food maintained at the facility. The hot water temperature was measured at 110.6 degree F which is within the required range. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is maintained.


Staff and Residents files are stored and maintained at the facility. LPAs reviewed 5 resident and 4 staff files to ensure all required forms are in their files. One of the resident files did not have the TB test results upon admission. Medications are centrally stored and locked. LPA reviewed medications and there are no discrepancies. The facility accepts and retains residents with dementia and/or hospice. The facility has a "no smoking oxygen in use" sign posted at the facility and in front of the resident's room. Emergency Disaster Plan is easily accessible and disaster drills are conducted monthly.

A deficiency is issued on the LIC809D. An exit interview was held and a copy of this report was given to the administrator.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/29/2024 03:50 PM - It Cannot Be Edited


Created By: Cynthia D Chan On 10/29/2024 at 03:34 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: A BELOVED HOME OF DIAMOND BAR
FACILITY NUMBER: 198603604

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
87458 Medical Assessment
(b) The medical assessment shall include, but not be limited to:
(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in Resident #5 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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The licensee shall ensure all residents upon admission has a medical assessment with TB test results within the past year.
This POC has been cleared today as proof of TB chest x-ray was completed on 5/21/24 for Resident #5.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:
DATE: 10/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2024


LIC809 (FAS) - (06/04)
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